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Nemaha Valley Community Hospital

Nemaha Valley Community Hospital

Master Plan Report

by

15 July 2019

Nemaha Valley Community Hospital

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Study Overview

15 July 2019

Data Analysis Observations & Recommendations Master Planning Options Cost Opinion Facility Assessment Executive Summary

Nemaha Valley Community Hospital

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Study Overview

15 July 2019

Introduction

In November 2018, Nemaha Valley Community Hospital engaged Health Facilities Group, LLC to create a new Facility Assessment and Master Plan Report to analyze the existing facility and identify

• pportunities for future development. This report is

the result of collaboration between Nemaha Valley Community Hospital and HFG. In the process of assembling the data and conclusions presented in this report, Tim Dudte, Jennifer Unrein, and Rick Wilson of HFG; and Brian Henry and Brett Walbridge

• f

PEC conducted an investigative tour of the hospital and clinic, interviewed administration and key hospital staff, and analyzed patient and service line data provided by the hospital. Kiley Floyd, Mike Stallbaumer, and the NVCH staff provided guidance and direction on behalf of the hospital and were instrumental in the formation of this report.

Project Team

Nemaha Valley Community Hospital Kiley Floyd, CEO Mike Stallbaumer, Maintenance Manager Health Facilities Group Tim Dudte, Medical Planner Rick Wilson, Medical Planner Jennifer Unrein, Project Architect Professional Engineering Consultants Brian Henry, Mechanical Engineer Brett Walbridge, Electrical Engineer

Process

The process of creating this Master Plan included the following elements: 1. Data acquisition – HFG acquired numerical data in the form of statistical information from the hospital’s records, and functional and

• perational data from interviews with key

hospital staff 2. Evaluation of the existing facility, site, and data 3. Preparation of preliminary Space Summary and Project Programming information 4. Development of alternative plan options with

• pinion on probable costs

5. Presentation of the findings and options

Nemaha Valley Community Hospital

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Data Analysis Observations & Recommendations Master Planning Options Cost Opinion Facility Assessment Executive Summary

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Executive Summary

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Existing Conditions

The facility is around 10-30 years old, depending on the phase of construction, and was built to deliver an inpatient model of care. There were fewer (but emerging) technologies available for care delivery, and this is evident in the structural bay; Mechanical, Electrical, and Plumbing (MEP) infrastructure; departmental adjacencies; and room and department sizes. There is adequate parking spaces for the staff,

• utpatients and clinic patients, and visitors.

The building entrance is clearly indicated with a drop-off canopy. The exterior of the building appears to be generally sound and in good repair. Several FGI Guidelines deficiencies would need to be corrected if using an addition/remodel approach.

Patient Data Analysis

The inpatient data shows general growth over the past six years. The annual patient days had been declining until a significant increase in 2016-2017, then a modest decline again in 2018. Census analysis shows increases in the max and 98% census for both swing and medical acute inpatients. Rehab therapies (PT/OT/RT/CR), ED, Lab, and Imaging have also been increasing since 2016. The PT/OT existing space is appropriately sized for the current equipment and support spaces, but staff wants to provide hydrotherapy, which will require additional treatment and support space. The imaging department has dedicated rooms for X- ray, CT, Mammo, Sono, and DEXA, but they are spread out, leading to staff inefficiencies. The current clinic is adequately sized for the providers on staff, and the facility has adequate space for the specialty clinic with visiting specialists

• n rotation, though administration asked about

increasing the quantity of specialist exam rooms.

Looking Forward

The building appears to be in good structural condition, but the structural bay size and the roof form hinder addition/remodel options. Though there are numerous issues, the primary needs are as follows:

• 1. The

Emergency department needs access control and a dedicated waiting room and decontamination facilities. Ideally, ED would be located closer to the Inpatient unit’s Nurse Station for better efficiency.

• 2. The Surgery suite needs additional equipment

storage space, scope cleaning space, and staff support spaces.

• 3. The Imaging suite needs to be consolidated to

improve efficiency and reduce patient confusion.

• 4. The Respiratory Therapy department needs to

be expanded and relocated to allow Lab the space to expand.

• 5. The Inpatient unit has undersized rooms that

lack accessible toilet/shower rooms. The size and accessibility issues should be addressed in any major expansion/remodel project. There are opportunities to expand the building area to the east and west, which would provide the space necessary to solve the majority of the functional relationship problems that currently exist.

Nemaha Valley Community Hospital

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Data Analysis Observations & Recommendations Master Planning Options Cost Opinion Facility Assessment Executive Summary

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Facility Assessment

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Area for Future Development Owned Property Future Development and/or Temporary Structures

Overview / Analysis

Nemaha Valley Community Hospital is located on Community Drive between Main and Branch Streets in Seneca, Kansas on the west central side of town in a primarily civic / industrial area with a field to the west, light industry to the southeast, a water park to the northeast, and ball fields to the north. There are 171

• ff-street

parking spaces serving the Hospital (65) and Clinic (106). The hospital property is landlocked by

• ther

development

• n

the north, south, and east, and by a street on the

• northeast. To the west is farmland.

The area east and west of the hospital could provide growth space.

} Site } Property

N

Main Entrance

Clinic Existing Hospital

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Analysis

There is adequate off-street parking

• n the site. However, an addition to

the facility would need new parking to replace any existing parking lost due to construction and to accommodate the new services provided. Site circulation is straightforward and clearly marked with signage. The perimeter drive can accommodate ambulance and service vehicles in addition to staff and patient traffic. The building entrance is clearly marked with a drive-up drop-off canopy and signage. The Emergency entrance is shared between ambulance and walk-up patients, which can be a problem.

} Site } Site Circulation, Parking, Building Entry Points

Ambulance & Service Path

• f Travel

PT Entrance (lower level) Staff and Patient Parking Clinic Parking Staff Parking PT/OT Parking

N

Main Entrance

Clinic Existing Hospital

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Utilities at street

Analysis

The primary opportunities for growth

• n the existing site are at the east and

west perimeter of the existing hospital. Any parking lost to construction would need to be replaced. The primary challenge to expanding

• n

the southeast is the narrow drive/parking and the proximity to the helipad. This is particularly challenging due to the need for growth space for the Emergency department. A secondary opportunity is to build a freestanding structure west of the perimeter drive, but this could create some logistical challenges, depending

• n the services provided.

} Site } Potential Building Locations

Areas available for construction

N

Main Entrance

Clinic Existing Hospital

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Analysis

Parking Requirements (Zoning) Hospital* 42 Clinic (4 providers)† 106 Total 148 Parking Provided (Existing) Hospital 65 Clinic (6+1 specialty) 106 Total 171 There is ample off-street parking per the zoning regulations, and to meet practical needs. Although there is no provision for parking for outpatient services in the regulations, the parking provided exceeds the minimum zoning requirements sufficiently to account for current needs.

* Zoning requires 1 space for every 2 inpatient beds plus 1 per 3 employees plus 1 per staff doctor. There is no parking provision for outpatient services † Zoning requires 3 parking spaces per exam room and 1 space per provider or employee

} Site } Parking

44 32 42 15 23 15

N

Clinic Existing Hospital

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Entry The main entrance is clearly marked architecturally with a circle drop-off drive and canopy. The Emergency entrance is also readily identifiable by signage and a drop-off/ambulance canopy. Paving The flatwork (paving, sidewalks) appear to be in generally good condition, though some areas exhibit cracking and/or spalling. Walks The sidewalks are in generally good condition, though some areas exhibit cracking and/or spalling. Ramps, Stairs, and Retaining Walls The stairs and ramp outside of the Dietary entrance appear to be in good condition, though there is some spalling at the ramp guardrail posts. One of these that appears to have been worse than the others has been

• patched. Many walls have rust stains from reinforcing that is oxidizing. While this is primarily an aesthetic

issue now, it has the potential to affect the surface of the paving as the expanding rusting reinforcing weakens the concrete, possibly leading to spalling or cracking which will in turn allow more water to reach the reinforcing, accelerating the oxidation process as well as exacerbating the freeze-thaw effects on the concrete. Helipad The helipad was recently relocated southeast of its previous location. Utilities Utilities run along the street and the west property line. Opportunities There is adequate land southwest of the hospital for an addition, and land west of the perimeter drive for

• utbuildings.

} Site } Condition

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} Building } Years Built

Building Phases

1989 Original Hospital 2009 East Addition PLAN NORTH

1989 2009

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} Building } Exterior

General The building exterior is generally in good condition. It is evident that the maintenance staff is handling issues as they arise in a timely manner. Issues listed below are items observed during the assessment visit that maintenance staff have likewise observed and prioritized for repair. Walls The exterior walls are primarily brick veneer on metal stud framing. Generally, the masonry is in good condition except for some settlement cracking at a few locations. Mortar cracks should be repointed to prevent moisture infiltration that could lead to mold issues in the wall cavity. Wall Caps / Fasciae / Flashing / Soffits Parapet caps, metal fascia, and metal roof edges generally appear to be in good condition. Some soffit areas are damaged and need repair near the ambulance canopy. Roof The roof system on the hospital is composite shingles on an insulating substrate on metal deck. The clinic roof is fully adhered TPO. Staff did not report any roof leaks at the hospital or clinic. Gutters / Downspouts / Scuppers The gutters, downspouts, and scuppers appear to be in good condition. Windows The windows appear to be original to their phase of construction and generally appear to be in fair condition, exhibiting some wear, weathering, and occasional separation at joints. Many windows need to be re-caulked. Doors Exterior doors appear to be original to their phase of construction and include both hollow metal-frame units with hollow-core metal doors and aluminum frame units. All doors appear to be in good condition. Caulking There is an expansion joint near the ED that needs to be re-caulked to prevent water infiltration.

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} Building } Interior

General The building interiors are in varying conditions and of different ages, with some elements having been recently updated while others are in their original condition. Floors Most of the floors in the hospital are original and in fair condition. The floors in surgery in particular are in poor condition, with seams pulling apart and various areas discoloring. VCT flooring in housekeeping closets is often discolored from water or chemicals. Walls Walls in the building generally appear to be in fair to good condition. Wall construction is drywall on metal studs. Walls in higher equipment traffic areas exhibit some impact marks (e.g. Acute care, Surgery, etc.), and there are areas in Surgery that exhibit settlement cracking.

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} Building } Interior

Ceilings / Soffits Ceilings are predominantly lay-in acoustic tile with some ceilings and soffits being painted gypsum board or plaster. Ceiling conditions vary from fair to good condition with the primary issue being age. A secondary issue is staining from leaks that have since been resolved, but these are infrequent. A few of the ceiling tiles in Surgery should be replaced due to edge damage. Windows Windows in the hospital appear to be original to their phase of construction. Some sills and walls adjacent to window jambs are showing signs of age. Doors Doors are typically solid- or hollow-core wood doors in varying conditions, with some metal-frame cross-corridor doors at the inpatient wing and metal doors at some service areas such as the Boiler Room. As expected, doors and/or frames in higher traffic areas or with narrower openings exhibit more wear than those in areas with lower traffic or less equipment movement or wider clearances. Most door hardware complies with accessibility requirements, but some doors still lack lever-type hardware.

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} Building } Interior

Entrances & Destinations

Diagram illustrates the locations

• f
• utpatient

services (clinics, therapies, procedures/surgery, and diagnostics) and Emergency relative to inpatient locations and the various building entrance points. Other than the Rural Health Clinic, there is little consolidation of outpatient services; few services are near the main entrance, leading to a long travel distance and greater chance for patients to lose their way and possibly wander into inpatient care areas; the spaces for outpatient services are too small; and the ED is undersized, lacks access control and security, and is remote from the inpatient Nurse Station which serves the ED after hours.

Inpatient Emergency Outpatient Entrance OP Path of Travel ED/IP/OP Clash Zone

Parking

Main Hospital Entrance ED Entrance (Ambulance and Public)

Parking Lower Level Parking

PLAN NORTH

Parking

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} Building } Interior

Patient Rooms

Diagram illustrates the size of existing patient rooms compared to the current Standard of Care for single-patient rooms.

Emergency Department

Diagram illustrates the size of existing trauma rooms compared to the current Standard of Care.

Imaging Suite

Diagram illustrates the size of the existing CT scan room compared to the current Standard of Care.

Existing Patient Room Standard of Care Existing Trauma Room Standard of Care Existing CT/Control Room Standard of Care

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} Building } Departments

Overview

On 27 February 2019, HFG conducted interviews with department heads and key staff regarding existing conditions, workflows, and projected needs in the various departments of the hospital. The main points of those discussions, together with HFG’s observations from the facility assessment tour are presented on the following pages as narrative information with selected Action Items that summarize design goals for the department. Photos that illustrate the departments and key issues in the departments are on the right edge.

Guidelines Issues

The 1996-97 AIA Guidelines for Design and Construction of Healthcare Facilities are the standards currently adopted by the State of Kansas. However, HFG typically reviews facilities under, and designs to, the most recent FGI Guidelines, which is currently the 2018 edition. Existing conditions that do not comply are typically grandfathered until a renovation or other major construction project impacts the space, which triggers compliance reviews. Those conditions are listed here as a general reference for major issues that would need to be corrected if the space was modified.

Accessibility Issues

Many conditions that do not meet current Accessibility Guidelines (2010 Americans with Disabilities Act) are noted in this section.

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} Building } Departments

Admin / Finance / HR

CEO: Kiley Floyd FTEs (largest shift): 6 Existing DGSF: 1603 SF Administration, Finance, and HR currently share

• ffice and support space. Any future building

projects should try to co-locate offices to share support space but still provide privacy and allow for future growth. Administration currently consists of a CEO and CFO with offices in the Admin suite, and a DON whose

• ffice is in the Acute Care area. The support staff

are in cubicles or offices behind the Admin Assistant’s desk. The Foundation office is located in the Clinic lobby and is to remain there. With the current configuration, the CFO becomes the de facto gatekeeper when the Admin Assistant is away, while the HR director does not have good public access. The HR/Finance assistant is in a cubicle but works with sensitive materials. HR needs an interview space, either an office for 4- 5 extra people for orientation / training or proximity to a general Education classroom with a small storage closet, and access to a copy/work room. Action Items

• Reconfigure space to provide more public

access to HR and more privacy to CFO

• Provide office for HR/Finance assistant
• Maintain corridor access for CEO
• Provide new Board / Meeting / Education Room
• Provide a vacant office for Part Time / PRN staff

to use

Guidelines Issues

2.1-6.3.2.1 Lacking space for private interviews for admissions 2.1-6.4 Lockers, lounges, and toilets for employees are required, and are required to be separate from those provided for the public

Accessibility Issues

• Some

doors lack lever-type hardware and dimensional clearances

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} Building } Departments

Business Office

Director: Lori Huerter FTEs (largest shift): 9 Existing DGSF: 1917 SF The Business Office serves both the Clinic and the

• Hospital. The design includes a general reception

desk with two enclosed admitting stations, but the stations are being used as offices with check-in happening at the open reception desk, leading to a lack of patient privacy. There is a need for an additional patient finance workstation. Action Items

• Utilize the HIPAA-compliant admissions stations

as intended

Guidelines Issues

2.1-6.3.2.1 Lacking space for private interviews for admissions 2.1-6.4 Lockers, lounges, and toilets for employees are required, and are required to be separate from those provided for the public

Accessibility Issues

• Some

doors lack lever-type hardware and dimensional clearances

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} Building } Departments

Clinical Lab

Manager: Katherine Bauerle FTEs (largest shift): 5 Existing DGSF: 1162 SF The clinical lab is undersized, causing staffing and space utilization inefficiencies. The layout dictates that RT patients use the Lab Draw entrance, causing confusion for patients and decreasing patient privacy for draws. The original draw stations were too narrow, so the second draw station is not curtained, causing patients to have no privacy. The lab lacks counter space, general storage space for supplies and consumables, and draw space. There is inadequate space for more equipment and for the limited microbiology procedures performed. Action Items

• Reconfigure the south part of the lab space to

accommodate more countertop work areas, relocated refrigerators and blood bank, and a new hooded micro room in the existing Office.

• Reconfigure the draw area and the existing RT

space to provide a HIPAA-compliant draw area for two chair and a work counter with supply storage

• Reconfigure the area between draw and lab for

a new Director’s Office and Tech work area

Guidelines Issues

2.4-4.1.2.4 Storage for supplies used in the laboratory is provided as required, however it is undersized

Accessibility Issues

• Some doors lack dimensional clearances

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} Building } Departments

Dietary

Manager: Donna Haug FTEs (largest shift): 4 Existing DGSF: 1642 SF The existing kitchen is slightly undersized, which leads to inefficiency. Limited capacity for tray prep and cold storage are the main issues. Reach-in freezers and refrigerators take up valuable floor

• space. The staff dining room is adequately sized.

Staff reported that they would prefer a walk-in freezer / cooler unit. Action Items

• Provide walk-in cold storage to free up floor and

wall space for more counter space

• Provide new kitchen equipment as needed

Accessibility Issues

• Doors

lack lever-type hardware and /

• r

dimensional clearances

Guidelines Issues

2.1-4.3.3.3 Space shall be provided for the following function to support food service cart distribution – storage for carts, loading of carts for distribution, distributing meals, receiving soiled carts, sanitizing carts 2.1-4.3.4 Provide a soak sink and 3-compartment sink 2.1-4.3.9.2 Toilet rooms provided adjacent to or directly accessible to department 2.1-4.3.9.3 Lockers or another form of lockable storage for food and nutrition services staff shall be provided

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} Building } Departments

Emergency

Manager: Courtney Strathman FTEs (largest shift): Existing DGSF: 1106 SF The Emergency department uses public corridors for circulation which reduces patient visual and acoustic privacy. There is no dictation space for the ED provider. Acute nursing staff care for ED patients, but the only Nurse Station is far removed from the Trauma & Treatment rooms. The lack of department access control makes it difficult to keep family members or other visitors in the Waiting Room (which is shared with Imaging), and they tend to mill around in the corridors waiting for news about the patient. There is no decontamination room, but staff stated that the portable decontamination equipment is adequate for their needs. One ED treatment room has been converted to DEXA, introducing unrelated traffic into the department. Staff prefers having four beds. The ED Supervisor’s office needs to be lockable. Action Items

• Create a distinct department that is easily

served from the Acute unit with contiguous access to Imaging and where public walk-in traffic is separated from trauma/ambulance traffic, and which has adequate access control

• Provide doctor’s dictation space
• Provide a covered entrance for the Walk-In ER

Entrance

• Provide an ambulance garage for weather

protection and access control

• Provide a locking office for the ED Supervisor

Guidelines Issues

2.2-3.1.2.2 Ambulance entrance shall provide a minimum of 6 feet in clear width to accommodate gurneys for patient of size, mobile patient lift devices and accompanying attendants. 2.2-3.1.2.3 Locate public waiting area so staff can

• bserve

and control access to the treatment room 2.4-3.2.2 Observation Bed with full cardiac monitoring is required. Access to radiography and fluoroscopy services are also required.

Accessibility Issues

• Doors lack appropriate clearances
• Lack accessible handwashing sinks
• Missing required grab bars in public restroom

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} Building } Departments

EVS / Laundry

Manager: Brandi Doss FTEs (largest shift): 5 Existing DGSF: 653 SF / 598 SF Environmental Services (EVS), Laundry, and Materials Management are under the same director. EVS space is reported as adequate for present and anticipated future needs, other than needing an enclosed, locking biohazard storage room. The Laundry department needs additional folding space and linen storage space. Materials Management is addressed separately. Action Items

• Maintain adequate storage for equipment and

supplies

• Provide additional laundry folding and clean

linen storage space

• Provide an enclosed, locking biohazard storage

room with refrigerated storage capability

Guidelines Issues

2.1-5.2.2 A separate soiled linen holding room with a hand washing station is required; a clean linen storage room is required; 2.1-5.5.2 Facilities for cleaning and sanitizing carts are required

Accessibility Issues

• Some doors lack lever-type hardware and / or

dimensional clearances

• Handwash

sink does not meet accessibility requirements

• Corridors are used as storage not allowing required

clearances to be met

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} Building } Departments

HIM

Director: Kristie Porting FTEs (largest shift): 8 Existing DGSF: 1120 SF HIM is tight on space, with up to 8 staff present at a

• time. Paper files are stored in the basement and

are being scanned as time and budget allow. Patients need access to HIM to pick up paper records for referral visits. Action Items

• Provide public access to HIM
• Provide

adequate

• pen
• ffice

space and director’s office

• Provide proximity to paper files
• Provide scanning station

Guidelines Issues

2.1-6.4 Lockers, lounges, and toilets for employees are required, and are required to be separate from those provided for the public

Accessibility Issues

• Some

doors lack lever-type hardware and dimensional clearances

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IT

IT: Mark Wessel FTEs (largest shift): 2 Existing DGSF: 1783 SF The IT office / work area is currently located in the basement adjacent to Laundry and the Maintenance workshop, and claims a lot of unexcavated space under the Acute unit for storage of antiquated equipment. The server room is in the west basement under Administration. The Maintenance Director’s office is in the IT Office / Work area, causing privacy problems for employee conversations. IT would appreciate being more centrally located, as the present location presents a larger travel distance for Clinic support call responses. The IT storage footprint could be significantly reduced by creating a concrete floor and installing shelving for equipment storage. Action Items

• Provide a more central location
• Provide appropriate equipment storage

} Building } Departments

Guidelines Issues

2.1-6.4 Lockers, lounges, and toilets for employees are required, and are required to be separate from those provided for the public

Accessibility Issues

• Doors lack lever-type hardware and dimensional

clearances

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} Building } Departments

Imaging

Manager: Ronda Sunnenberg FTEs (largest shift): 5 Existing DGSF: 1839 SF The Imaging department offers in-house X-ray, CT, Ultrasound, DEXA, and Mammo, and mobile MRI Nuclear Med, and PET services. DEXA is located in an ED Treatment Room, causing unrelated traffic in the ED and decreased efficiency. Ultrasound and Mammo are housed in recently- remodeled adjacent space and are adequate, but their location outside the department leads to some staffing inefficiency. X-ray and CT are undersized, as are the tech work area, reading area, and director’s office. Toilet and changing rooms do not meet accessibility requirements. Staff does not have visual control of the waiting area or the corridor where arriving patients approach the department. X-ray is currently CR, but staff expects to be switching to DR within the next 3 years. With the exception of Mammo, most reads are outsourced. Action Items

• Design a contiguous imaging suite with direct

access to the Emergency Department if possible;

• therwise,

minimize the distance crossing or traveling in public corridors

• Provide adequate space for all modalities

Guidelines Issues

2.2-3.4.2.2 Imaging rooms shall be sized to provide 4 feet on all circulating sides of the patient table 2.2-3.4.2.4 Doors are required to have lever-type or push-pull-type hardware. Doorways to imaging rooms are required to have a clear

• pening width of 45.5 inches.

Required Medical Gasses, listed in Table 2.1-3, include (1) each of Oxygen, Vacuum, and Medical Air per Class 1 Imaging Room. 2.2-3.4.4.4 Mammography rooms shall be sized to provide 3 feet on all circulating sides of the patient position 2.2-3.4.6.1 Ultrasound rooms shall be sized to have 3 feet on all circulating sides of the patient table 2.2-3.4.8 The department lacks various required supports spaces (centralized reception area / control desk, consultation areas, medication storage room, clean supply, soiled holding, equipment supply, lounge, waiting, staff & patient toilets, etc.)

Accessibility Issues

• Doors lack lever-type hardware and dimensional

clearances

• Patient toilet and dress rooms do not meet

accessibility requirements

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} Building } Departments

Inpatient (Acute)

DON (Acute & Swing): Lynda Cross FTEs (largest shift, Acute & Swing): 4 Existing DGSF (Acute & Swing): 9209 SF The Acute wing consists of the Nurse Station, DON and other offices, Meds room/pharmacy, support spaces, and 20 inpatient rooms; however, one room is generally used as an outpatient infusion room,

• ne room is used for RT PFT, 2 rooms are used for

pre/post, and 3 rooms are used for offices, leaving 13 rooms for acute and swing patients. None of the patient toilet rooms comply with accessibility requirements. Staff needs a reporting / conference / break room to minimize noise in the unit during reporting or team/staff meetings. Dictation space is also needed for provider privacy and to prevent disrupting nursing activities at the nurse station. Staff reports a lack of storage; undersized nurse station; lack of office space; need for dedicated staff lockers undersized Pharmacy/Meds; ED too far away; too few power outlets; and various privacy issues. Action Items

• Provide appropriately sized patient rooms with

accessible toilet / shower rooms and adequate bedside power and gas outlets

• Provide chart/report, locker, and dictation space
• Design to allow floor staff to care for ED patients
• Provide space for automatic dispensing units for

medications in right-sized meds / pharmacy

Guidelines Issues

2.4-2.1.2 Provisions made for patient of size to accommodate the population expected to be served by the facility 2.1-7.2.2.5 Window net glazed area at least 9.6 SF 2.1-2.2.6 Patient toilet room shall have a bed-pan rinsing device 2.1-2.2.7 Bathing facility with space for an attendant shall be directly accessible to a toilet in a separate enclosure and shall be sized to allow entry of mobile lifts and shower gurney devices 2.4-2.2.4.5 Critical care rooms shall meet the electrical, med gas, and nurse call requirements in Table 2.1-1-3 2.1-2.8.9.2 Nourishment area requires a refrigerator, microwave, and space for temporary storage of food service implements as well as temporary storage of unused and soiled meal trays 2.1-2.8.13 Equipment and supply room shall be sized to provide a minimum of 10 SF per patient

• bed. Emergency equipment storage shall

not encroach on the minimum required corridor width. 2.4-2.2.9 Must provide required staff support spaces and family and visitor lounge

Accessibility Issues

• Many doors lack lever-type hardware and/or

dimensional clearances

• Patient toilet and shower rooms do not meet

accessibility requirements

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} Building } Departments

Guidelines Issues

2.2-2.9.3.2 Rooms shall have a minimum 325 SF with minimum wall width of 13 feet. A distinct space separate from the mother’s area shall be provided for infant stabilization and resuscitation 2.4-2.2.4.6 Storage for case carts, delivery equipment and bassinets shall be provided 2.4-2.2.4.7 A cesarean delivery room is immediately accessible to the delivery rooms; however it does not meet all of the requirements for this room

Accessibility Issues

• Many doors lack lever-type hardware and/or

dimensional clearances

• Patient room toilets and showers do not meet

accessibility requirements

Inpatient (OB)

Director: Dana Deters FTEs (largest shift, Acute & Swing): Existing DGSF (Acute & Swing): 2501 SF The OB unit is comprised of 3 LDR(P) rooms and support space, with a direct connection to the Surgery suite for C-sections. One of the LDR rooms does not have an exterior window and so technically cannot be used for Postpartum stays. There is no nurse station for the unit, so staff uses the Nursery work area as a nurse station. Staff has requested a fourth room to use for OB observation patients, and a rework of the support space to make better use of the available space. Action Items

• Provide an Observation room
• Provide adequate support space for the unit
• Provide a proper nurse station
• Retain staff circulation from the Acute nurse

station to the OB unit

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} Building } Departments

Inpatient (Swing)

The Acute unit has a varying Swing bed census with no distinct Swing Bed unit. The facility is lacking the required dining/activity room (must be sized at 55 SF per bed minimum). Other deficiencies are the same as for the Acute unit. Action Items

• Provide accessible toilet/shower rooms
• Provide adequate support space for the unit
• Provide the required dining / activity room

Guidelines Issues

2.1-7.2.2.5 Window net glazed area at least 9.6 SF 2.1-2.2.6 Patient toilet room shall have a bed-pan rinsing device 2.4-2.2.4.5 Critical care rooms shall meet the electrical, med gas, and nurse call requirements in Table 2.1-1-3 2.1-2.8.9.2 Nourishment area requires a refrigerator, microwave, and space for temporary storage of food service implements as well as temporary storage of unused and soiled meal trays 2.1-2.8.13 Equipment and supply room shall be sized to provide a minimum of 10 SF per patient

• bed. Emergency equipment storage shall

not encroach on the minimum required corridor width. 2.4-2.18.2.1 A minimum of 55 SF per bed shall be provided for dining, recreation and day spaces in either separate or adjoining spaces 2.4-2.18.3 Access to the outdoor areas

Accessibility Issues

• Many doors lack lever-type hardware and/or

dimensional clearances

• Patient toilet and shower rooms do not meet

accessibility requirements

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} Building } Departments

Materials Management

Manager: Brandi Doss FTEs (largest shift): 1 Existing DGSF: 913 SF The Materials Management department generally appears to be undersized, lacking adequate general storage and receiving/unpacking space. Staff had no other comments. Action Items

• Provide adequate storage space with required

support spaces (paperwork, receiving, etc.)

Guidelines Issues

2.1-5.3.2.2 A receiving area separated from other

• ccupied building areas, waste staging

areas, and outgoing materials handing areas is required 2.1-5.3.3 General storage is required at 20 SF per patient bed plus 5% of the total floor area of

• utpatient areas.

2.1-5.4.1.1 Waste Management areas are required for the following waste types:

• Municipal Solid Waste
• Regulated Medical Waste
• Pharmaceutical Waste
• Anatomical Remains
• Hazardous Wastes
• Chemotherapy Wastes
• Universal Wastes
• Radiologic Wastes

Accessibility Issues

• Doors lack lever-type hardware and/or dimensional

clearances

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} Building } Departments

Maintenance

Manager: Mike Stallbaumer FTEs (largest shift): 2 Existing DGSF: 6733 SF The maintenance director’s office is shared with IT, causing privacy problems when having employee

• discussions. The maintenance workshop appears

to be undersized. Much of the maintenance storage is in the “unexcavated” part of the basement, and would be better served with a concrete floor and shelving units. There is a maintenance outbuilding to the south that is not counted in the DGSF. Action Items

• Provide adequate maintenance workshop with
• ffice & plans storage space

Guidelines Issues

None

Accessibility Issues

• Doors lack lever-type hardware and dimensional

clearances

• Restroom in mechanical room space does not meet

dimensional clearance requirement on the door and fixtures

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} Building } Departments

Pharmacy

Pharmacist: Travis Stallbaumer FTEs (largest shift): Existing DGSF: 74 SF The pharmacy is undersized and lacks required support spaces and elements (paperwork area, receiving, storage, fluids storage). There is a particular problem with not being able to store adequate quantities of IV bags. The pharmacy cannot presently support an

• ncology unit, which is in the near-term planning for

additional service lines. The ED needs a locking refrigerator for drug

• storage. All IV mixes are for immediate use. The

hospital is investigating purchasing automated dispensing units. As of HFG’s last visit, a consultant was scheduled to review the facility for USP 797/800 compliance and provide relevant action items. Action Items

• Provide an appropriately-sized pharmacy with

space for an automatic dispensing system and the requisite support space.

• Provide adequate size and quantity Med Room

for the inpatient unit and the ED, keeping dispensing units outside of patient care areas.

Guidelines Issues

2.1-4.2.2.1 The pharmacy lacks adequate space for receiving, unpacking, and inventory activities; countertop space for dispensing activities; an extemporaneous compounding area; an area for reviewing and recording; space for restocking carts; and security provisions for drugs and staff. 2.1-4.2.2.3 Separate storage is required for bulk storage, active storage, refrigerated storage, storage for volatile fluids and alcohol, secured lockable storage for narcotics and controlled drugs, general supply and equipment storage 2.1-4.2.3.2 The facility lacks a laminar flow workstation 2.1-4.2.9.1 Lounge, locker and toilet facilities shall be readily accessible to the pharmacy

Accessibility Issues

• Door lacks lever-type hardware and dimensional

clearances

• Sink does not meet dimensional clearance

requirements

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} Building } Departments

Physical Therapy

Manager: Tina Palic FTEs (largest shift): 5 Existing DGSF: 4561 SF The Physical Therapy department is adequately sized for current and near-term future needs. Staff would like to add hydrotherapy with an addition/remodel project. The exterior entrance is convenient to parking, providing easy access for patients, and is visible from the tech area so staff can monitor patients as they come in to see if they need assistance. The unit is also convenient to the inpatient unit via elevator for staff to provide service to those patients as well. Action Items

• Provide space for hydrotherapy in a building

addition project

Guidelines Issues

2.4-2.18.3.4 Facilities for collection of wet and soiled linen and other material shall be provided

Accessibility Issues

• Doors lack dimensional clearances

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} Building } Departments

Public Space

Manager:

• FTEs (largest shift):
• Existing DGSF:

9040 SF The public waiting area is at the main (front)

• entrance. There are two enclosed admissions

stations but they are being utilized as offices rather than for admissions. Admissions are being handled at the reception counter at the main waiting area that provides no acoustic privacy. There is a shared Imaging/ED waiting room at the east end of the main corridor with a water cooler / dispenser and a toilet that opens onto the corridor and onto the satellite imaging suite (ultrasound and mammo). Action Items

• Provide separate waiting areas for Emergency

and Imaging patients with the services required by the FGI Guidelines.

• Provide a securable entrance separate from the

main entrance for Emergency patients.

Guidelines Issues

2.1-6.2.2 Reception / Lobby areas shall include:

• Access to Information
• Public waiting area(s)
• Public toilet room(s)
• Provisions for telephone access
• Provisions for drinking water

2.1-6.2.7 When wheelchairs are provided for public use within the facility, a designated area for wheelchair storage, out of the required corridor width and directly accessible to the entrance, is required

Accessibility Issues

• The facility lacks drinking fountains that comply with

accessibility standards

• Public

restrooms do not meet accessibility standards

• Doors lack lever-type hardware and dimensional

clearances

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} Building } Departments

Respiratory Therapy

Manager: Dawn Osterhaus FTEs (largest shift): 3 Existing DGSF: 560 SF The Respiratory Therapy department, located essentially within the lab, is undersized and not well

• positioned. Due to adding a third staff person, the

PFT box had to be relocated to a patient room. Staff would like to relocate and consolidate their space with a treatment room and associated work/cleaning room, a single shared tech office, a DME storage room, and a DME fitting room. Action Items

• Provide adequate staff and patient space in a

consolidated department

Guidelines Issues

2.4-2.18.3.1 The therapy space shall be size to accommodate the equipment used. Currently storage space is not adequate. One individual treatment room with a minimum clear floor area of 80SF shall be provided. 2.4-2.18.3.3 A hand-wash station shall be provided immediately accessible to the room 2.4-2.18.3.4 Facilities for collection of wet and soiled linen and other material shall be provided

Accessibility Issues

• Doors lack dimensional clearances
• Hand sink is not accessible

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} Building } Departments

Surgery / Endoscopy

Director: Nichelle Koch FTEs (largest shift): 8 Existing DGSF: 2871 SF The Surgery / Endoscopy unit consists of (2) patient rooms designated for pre- and post-procedure rooms, an OR, a procedure room, a small PACU, and inadequate support space. The scope processing room is too small to accommodate newer cleaning equipment, so staff is relying on and maintaining their old cleaner. The unit can use up to 5 acute rooms for pre/post

• n busy days. However, the call system rings at the

Acute nurse station, not the PACU nurse station. Action Items

• Provide a single, contiguous department with the

needed endo and surgery capability with appropriate support spaces and HVAC equipment to meet current requirements

• Provide adequate power and gas outlets
• Provide universal pre/post/PACU stations to

save space

• Provide space for automatic dispensing units for

medications

Guidelines Issues

2.2-2.9.11.1 An operating room used for cesarean delivery shall have 440 SF clear floor area. Additional outlets and med gas are required. 2.2-3.3.3.6 Equipment storage room shall be provided in the semi-restricted area 2.1-3.4.4.3 The design of the Phase I recovery area shall provide observation of all patient care stations from the nurse station. 2.2-3.3.5.8 Nurse station with documentation area, clinical sink, medication safety zone, nourishment area with ice machine, and emergency equipment storage 2.2-3.11.4.2 Provide a two-basic sink in scope decontamination room with a 12” backsplash, eyewash station 2.2-3.3.8 Wheelchair storage space 2.4-3.3.10 Provide patient changing space with access to a toilet without passing through a public space and have provisions for secure storage

• f

patients belongings

Accessibility Issues

• Many

doors lack the required dimensional clearances

• Storage in corridors restricts the corridor width

below the required 8’-0” clearance

• The restrooms and showers do not meet the

required dimensional clearnances

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} Building } Departments

Clinics

Manager: Amy Jo Huerter FTEs (largest shift):

• Existing DGSF:

8713 SF The clinic is in a recent addition to the west of the

• hospital. The clinic is adequately sized and the

modular design allows for easy expansion. Staff reports that there is a lack of office space in the specialty clinic section due to an unrelated person being located in that office, which also leads to unrelated traffic through the Specialty Clinic

• space. There is also a slight lack of storage space

due to unrelated personnel in the main clinic. Relocating the unrelated personnel would solve the immediate needs. If the clinic grows, an expansion project may need to be considered in the future. Action Items

• Provide space in the hospital addition/remodel

project to offload personnel unrelated to clinic functions.

Guidelines Issues

None

Accessibility Issues

• None

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} Mechanical / Plumbing

Introduction

Brian Henry of PEC in Wichita conducted a Mechanical/Plumbing systems assessment during the team’s February 2019 site visit. A summary of his findings are shared here; the full assessment is included in the Appendix to this document. In general, the hospital’s HVAC systems are at capacity and/or nearing the end of their expected service life. In an addition/remodel scenario, all new equipment would be needed for the hospital.

Piping

There is only one domestic water service entrance (two are required by code). This means that any plumbing work would require loss of water for the whole building. The sanitary sewer lines appear to be in adequate condition. There is one domestic hot water storage tank in the hospital, meaning there is no code-required

• redundancy. The clinic addition is served by a separate

unit but there is no interconnection between the two

• systems. The valves of the hospital’s tank appear to be

leaking and in need of repair. The medical gas room does not appear to fully meet code requirements for ventilation. The medical gas equipment itself appears to be in good condition, but capacity of the system should be verified and corrective action taken if needed.

Mechanical

The boilers currently meet code requirements for dual- fuel capability and redundancy, but are near the end of their expected service life and should be considered for replacement with increased capacity in line with the goals of this master plan. Cooling is provided by 4-stage split condensing units. Though they are in fair to good condition, they lack the capacity for any building additions, they cannot maintain a constant discharge air temperature, and they utilize R-22 refrigerant, which is being phased out of production and will become increasingly costly to purchase. Maintenance costs will also rise as the equipment ages. There are humidifiers on AHUs 1 and 2 (AHU 2 serves Surgery). They appear to be in good condition. The Air Handling Units (AHUs) and attached equipment do not provide the best temperature and humidity control for critical patient care spaces. These systems should be replaced or upgraded in the next 3-5 years. The ORs do not have pressure monitors, lack proper airflow, and do not achieve the desired air temperature

• r humidity levels. However, achieving the desired air

temperatures may cause condensation problems if they are not anticipated. Controls are a mix of pneumatic and DDC systems. The pneumatic controls are gradually being upgraded to

• DDC. Moving forward, the upgrade path should take

into account the goals of this master plan to avoid replacing controls on older equipment that will itself be replaced in the near future.

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} Electrical

Introduction

Brett Walbridge of PEC in Wichita conducted an Electrical systems assessment during the team’s February 2019 site visit. A summary of his findings are shared here; the full assessment is included in the Appendix to this document. The electrical equipment is generally in good condition, and while the current configuration does not meet current code for new construction, no action is required until a project is undertaken.

Low Voltage Systems

The existing low voltage systems in the facility (fire alarm, nurse call, security, access control, voice, data, and CATV) appear to be up to date and expandable.

Main & Emergency Power

The existing main and emergency power distribution systems are not properly separated from each other, nor are they located in dedicated rooms. The emergency distribution is not split into life safety, critical, and equipment branch loads. A new emergency electrical equipment room should be created to separate normal and emergency power systems, and emergency power should be split into the three branches, ideally in conjunction with a major addition/remodel project.

Building Lighting

The current building lighting is fairly efficient. In any future addition or renovation, consider the following strategies: Provide energy efficient LED lighting fixtures Connect select lighting fixtures in corridors, egress paths, and at exterior doors to the life safety branch of the emergency electrical system. In ORs, provide dimmable LED lighting fixtures with integral battery packs in select fixtures and coordinate color temperature. Consider lighting fixtures with tunable color temperature to provide circadian support in inpatient areas. Limit light trespass into patient rooms. Provide automatic lighting controls in remodeled areas where such controls would not pose a threat to patients

• r staff.

Patient Rooms

Additional receptacles would be required to meet the minimum number required for general care space, and headwall devices are required to be served by at least

• ne critical power circuit and one normal power circuit.

New overbed lighting should be provided to allow for exam lighting as well as patient-controlled ambient and reading lights. The patient-controlled lighting functions should be integrated with the existing nurse call system.

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Data Analysis

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1333 1347 1571 1437 2125 1962 500 1000 1500 2000 2500 2013 2014 2015 2016 2017 2018

Patient Days by Year

OB ACUTE SWING

Analysis:

HFG requested actual daily census data to evaluate inpatient volumes to identify long-term historical trends and to determine an appropriate number of rooms and beds. Based on the data provided by the hospital, total patient days for 2018 are 47% higher than 2013, primarily due to increases in both Acute and Swing Bed volume, though OB volumes increased 8% over the same period. On average, Acute inpatient stays represent 51% of the total patient days, with Swing Beds comprising 40% and 0B making up 9% of the total patient days. The graph shows the patient days by service line (OB, Acute, Swing) per year. This helps show how the patient days vary by year and shows that the majority of patient days have historically come from Acute patients.

} Inpatient Data

The number of combined patient days generated by Acute and Swing Bed patients has grown considerably, mostly in the past two years. This is contrary to the nationwide trend of decreasing inpatient volumes, and a market analysis would be useful in identifying the source and impact of this growth. Knowing the causes and the expected peak growth would help guide the planning efforts for appropriate facility expansion.

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2 4 6 8 10 12 2013 2014 2015 2016 2017 2018

Swing Bed Census

Analysis:

Analysis of the actual daily census data of inpatient volumes can help determine an appropriate number of rooms and beds. The “98% line” is the room count needed to have single occupancy rooms for 98% of the year. For the remaining 2% of the year (generally around 7 days), double occupancy would be needed for a few rooms, the quantity of which is the difference between the max census and the 98% mark. The goal is to maximize the bed count without building private rooms that will be vacant for approximately 358 days per year. The OB census has been steady with a maximum of 3 patients, except in 2014, where there were two days with a census above 3 (max 5). Nationwide, there is a general downward trend in the acute/

• bservation/swing inpatient census. However, Nemaha Valley

Community Hospital has increased from 1333 to 1962 annual patient days from 2013 to 2018. Because of this upward trend, and to accommodate potential future growth HFG recommends 19 beds in the following mix: Acute / Swing (12) single rooms (2) super-single (double-occupancy capable) rooms OB (3) LDRP Acute to share rooms for overflow Postpartum If there is any concern about capacity, a market share study should be undertaken to identify relevant metrics and opportunities for growth.

} Inpatient Data

Inpatient Daily Census by Service Line

2 4 6 8 10 12 2013 2014 2015 2016 2017 2018

Acute Census

5 10 15 20 2013 2014 2015 2016 2017 2018

Total Census

MAX 98% AVG

1 2 3 4 5 6 2013 2014 2015 2016 2017 2018

OB Census

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3 3.5 4 4.5 5 1050 1100 1150 1200 1250 1300 1350 1400 1450 1500 2012 2013 2014 2015 2016 2017 2018

Emergency Department

Analysis:

Total ED patient volume (the blue area) has had an overall increase since 2012 and an absolute increase since 2015 after three years of declining volumes. The darker blue line shows average daily visits. Due to the potential for fluctuation in the number of daily visits, the Emergency Department should be designed for maximum flexibility. This could mean using Acute rooms for ED overflow due to the greater cost reimbursement. We recommend providing a triage/treatment room and two trauma rooms, with emphasis on using Acute rooms for ED overflow situations as needed.

} Emergency Department Data

Annual Visits Average Daily Visits

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2000 4000 6000 8000 2012 2013 2014 2015 2016 2017 2018

Radiology Annual Procedures

OP IP

2000 4000 6000 8000 2012 2013 2014 2015 2016 2017 2018

PT / OT / Speech Annual Visits

OP IP

50000 100000 150000 200000 2012 2013 2014 2015 2016 2017 2018

Clinical Lab Annual Procedures

OP IP

Analysis:

Generally, outpatient service volumes have been increasing since 2012, but with a slight decrease in PT/OT volumes over the past year. Lab volumes for 2018 are at a five-year high. Total imaging modalities have fluctuated in the range of 5300 to 6200. Physical Therapy is expecting to increase patient volumes and wants to add hydrotherapy services. Lab procedures are constrained by the current space, particularly regarding the draw area. Improving this space should improve throughput. Imaging is limited primarily by available space. Expansion of services along with proper location within the facility should increase volumes and improve patient satisfaction. We recommend providing the necessary hydrotherapy space for PT; increasing the general lab size and improving the Lab Draw/Specimen collection area; and increasing the space for the provided modalities in Imaging.

} Outpatient Data

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Data Analysis

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1000 2000 3000 4000 2012 2013 2014 2015 2016 2017 2018

Cardio Rehab Visits

Phase 3 Phase 2

500 1000 1500 2012 2013 2014 2015 2016 2017 2018

OR Procedures

OP IP

1000 2000 3000 4000 2012 2013 2014 2015 2016 2017 2018

RT Annual Visits

OP IP

Analysis:

Respiratory Therapy has increased significantly over the past two years, following a slight overall 4-year decline. The department has

• utgrown its allocated space, taking over an inpatient room for PFT

and treatments, and uses two inpatient rooms for sleep studies. Surgery Procedures have declined since 2012, with the exception of a slight increase in 2016. Improving the physical characteristics of the Surgery Suite should help improve both patient and provider satisfaction, and hopefully increase volumes. Cardio Rehab visits have been declining for Phase 3 patients, and generally steady for Phase 2 patients. We recommend relocating RT into larger space while maintaining its proximity to the front door. The Surgery Suite should be updated to provide adequate HVAC, storage, and Pre/Post/PACU space. Cardio Rehab could be co-located with PT/OT or located nearby to improve patient access and proximity to parking.

} Outpatient Data

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Observations & Recommendations

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Existing 11’-0” 14’-0” to 16’-0” Typical Modern Hospital Building Sections

New Structural Bay width for a modern hospital is between 27’ and 32’

Existing Hospital

Floor-to-roof heights in the existing hospital building are unsuitable for many hospital uses today. The space between the ceiling and the floor above would be tight with a flat roof, but the sloped roof provides adequate space for the infrastructure needed for HVAC ductwork, medical gases, plumbing, IT cabling, emergency & normal electrical wiring, low voltage systems, and fire protection.

Typical Modern Hospital

Floor-to-roof heights accommodate the infrastructure needed, with space to allow for future elements.

Structural Considerations

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Observations & Recommendations

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Modern Hospital Building Section (Space & Dimension Issues) 9’h

16’ to 18’h @ parapet

5’ to 7’h 8’w

Structural Considerations

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Design Intent

Department Description

Admitting

Protect patient privacy (HIPPA)

Admin / BO

Co-locate to share support spaces and for staff proximity; need another conference room

Clinics

Protect patient privacy (HIPPA); provide additional Financial Counseling workstations

Dietary

New walk-in freezer/cooler

Emergency

Provide adequately sized rooms; improve security and access control

HIM

Provide adequate space for staff and files

Imaging / Lab

Expand Lab and Imaging to provide right-sized spaces; maintain Imaging proximity to ED; provide PACS viewing room out of traffic

Inpatient

Provide (14 single ISB/SSB/Acute rooms, proximity to ED, ability to cover outpatient services after hours; provide quiet space for dictation;; provide computers in patient rooms for bedside charting; provide adequate quantity of power outlets; provide space for equipment out of the corridor

IT

Provide more centralized office space; provide adequate cooling (with redundancy) and temperature checking

Laundry

Renovate laundry space

Materials Management

Provide adequate materials storage, unpacking, and work space

Pharmacy

Provide adequately sized pharmacy with space for automated dispensing & control units

PT / OT

Provide space for hydrotherapy

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Project Program

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Project Program

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Observations & Recommendations

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Project Program

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Observations & Recommendations

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Project Program

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Observations & Recommendations

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Project Program

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Observations & Recommendations

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Project Program

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Observations & Recommendations

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Project Program

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Observations & Recommendations

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Project Program

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Observations & Recommendations

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Project Program

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Observations & Recommendations

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Project Program

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Observations & Recommendations

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Project Program

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Project Program

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Observations & Recommendations

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Project Program

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Observations & Recommendations

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Project Program

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Observations & Recommendations

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Inpatient / Outpatient Separation

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Plan Options

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Existing Departments Review

Mechanical Rural Health Clinic Storage IT Pre/Post Imaging Specialty Clinic PT/OT/Speech

Main Level

Administration

Basement

Cardio Rehab HIM Conference Center Surgery

PLAN NORTH

Storage Mechanical IT Server Room Bus Ofc Records HIM Records Acute Storage EVS Maintenance Laundry Maintenance Matls Mgmt Office Emergency Acute Care Outpat Svcs Pharmacy Dietary Materials Management Imaging (DEXA) Clinical Lab Foundation Office Business Office RT

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Concept | Department Plan

PLAN NORTH

Mechanical Biomed Storage Hydrotherapy

Basement

Cardio Rehab HIM Matls Mgmt EVS Vacant Laundry Maintenance Maint Office IT Offices Oncology Storage PT/OT/Speech

Main Level

Rural Health Clinic Clinical Lab Pre/Post Sleep Study Specialty Clinic Foundation Office RT Surgery Acute Care Business Office Imaging Administration Pharmacy Conference / Training Conference Center Dietary Emergency Outpatient

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Plan Options

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Concept | Construction Intensity

PLAN NORTH

Basement Main Level

Addition Major Remodel Unchanged Major Remodel Unchanged Major Remodel Addition Addition Minor Remodel

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Plan Options

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Overview

As with any addition-remodel project, the goal is to solve as many issues as possible within the constraints

• f

the budget and the existing

• conditions. This means that not every problem will

have an ideal solution, and that getting closer to an ideal solution will have cost implications due to added building area and/or phasing construction to keep services functioning during the renovation work. In the proposed concept, the goal was to solve the top five issues as identified in the Executive Summary (ED, Surgery, Imaging, RT/Lab, Acute) in the most expedient and cost-effective way possible. This meant not addressing the most pressing needs first, to simplify phasing and reduce overall project cost. Specifically, Materials Management and Pharmacy need to be relocated for the Emergency Department to expand in place; the Inpatient unit needs to be relocated outside of its current footprint to provide growth space for Surgery, Outpatient Services, and RT; the existing ED Trauma rooms need to be vacated to provide growth space for Imaging; Cardio Rehab and HIM need to be relocated to provide additional Conferencing and Education space; and all

• f these functions must be kept in operation during

the transitions, and must be placed in logical locations to maintain (or fix) the proper functional relationships to other departments, services, and access points.

Challenges

The primary challenge to this concept is that two of the major needs (ED and Imaging) are not addressed until late in the project and may not be addressed at all if the scope of the initial project is reduced. A secondary challenge is that the first major addition, while providing most of the needed growth space for making everything else possible, costs more than addressing ED and Imaging as the Phase 1 solution. However, construction costs are projected to increase

• ver time, so undertaking a larger project sooner may

make better fiscal sense.

Benefits

The primary benefit to this concept is simplifying construction phasing as much as possible with an in- situ remodel of numerous departments. The benefit to reducing phasing complexity is a reduction in total project cost. This is achieved by providing growth space in the major addition as the first phase. The secondary benefit is that the phasing addresses Inpatient needs first, which will should improve the

• verall CMS reimbursement, since Inpatient utilization

is the highest reimbursement rate.

Concept Analysis

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Plan Options

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Concept | Alternate Phasing (Phases 1 & 2)

PLAN NORTH

Mechanical Storage Storage

Basement

Bus Office Stor EVS Matls Mgmt HIM Laundry Maintenance Maint Office IT Offices Storage Storage PT/OT/Speech

Main Level

Rural Health Clinic RT Acute Care RT Specialty Clinic Foundation Office Sleep Study / Pre/Post-Op Surgery Outpatient Business Office Imaging Administration Pharmacy Cardio Rehab Conference Center Dietary Emergency Clinical Lab

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Overview

The first concept phasing does not address ED and Imaging until late in the project, which leaves the possibility that they would not be addressed at all if the project scope is reduced. This alternate phasing concept results in the same final building configuration but achieves it in a different order.

Challenges

The primary challenge is finding homes for Materials Management and Pharmacy to allow expansion of the Emergency Department. To prevent disruption to deliveries, a portion of the Phase 3 site work would need to be undertaken in Phase 1. A secondary challenge is the financial impact, both as the additional direct cost of the phasing (potentially approaching $1 million) and as an impact to CMS reimbursement by diluting the cost report. This occurs by making the Acute area a smaller percentage of the building gross square feet (GSF) and increasing the percentage of lower reimbursement rate departments Emergency and Imaging. Other challenges include finding temporary locations for some offices during remodeling work in the east corridor and less space for Cardio Rehab.

Benefits

The main benefit to the alternate phasing approach is that ED and Imaging are addressed as the primary

• needs. The secondary benefit is that if the master plan

is split into two distinct projects, then the first project is smaller in scope. However, this “benefit” puts off the larger scope of work to a later date, when construction costs and interest rates will likely be higher.

Concept Analysis – Alternate Phasing

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Cost Opinion

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Building Construction $ 17.8M Site $ 1.4M CM Contingency (5%) $ 0.9M Inflation Contingency (4%) $ 0.7M Construction Subtotal* $ 20.8M Fees, Testing, Legal, etc. $ 1.5M FF&E $ 2.5M Owner’s Contingency (5%) $ 0.9M Project Costs Subtotal* $ 4.9M Project Total* $ 25.7M

Addition / Remodel – All Phases

* Costs in 2019 dollars; financing costs are NOT included Totals subject to rounding errors

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Cost Opinion

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Inpatient Addition $ 11.8M

(includes RT, Lab, Outpatient Services, OR Waiting, Basement shell space)

ED/Imaging Addition $ 5.6M

(includes Materials Management, Pharmacy, Cardio Rehab)

Surgery Remodel $ 3.5M Other Projects $ 4.8M

(includes Admin, Basement Commons, IT, Laundry, Maintenance, HIM Offices, Oncology Clinic, and Storage space)

Total* $ 25.7M

Addition / Remodel – Breakout

* Costs in 2019 dollars; financing costs are NOT included Totals subject to rounding errors. Phase costs do NOT include additional Inflation or mobilization costs

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Cost Opinion

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Building Construction $ 4.5M Site $ 0.5M CM Contingency (5%) $ 0.2M Inflation Contingency (4%) $ 0.2M Construction Subtotal* $ 5.4M Fees, Testing, Legal, etc. $ 0.4M FF&E $ 0.5M Owner’s Contingency (5%) $ 0.2M Project Costs Subtotal* $ 1.1M Project Total (Phases 1 & 2)* $ 6.5M

Addition / Remodel - ALTERNATE PHASING (Phases 1 & 2)

* Costs in 2019 dollars; financing costs are NOT included Totals subject to rounding errors

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Cost Opinion

15 July 2019

Building Construction $ 14.0M Site $ 0.9M CM Contingency (5%) $ 0.7M Inflation Contingency (4%) $ 0.6M Construction Subtotal* $ 16.2M Fees, Testing, Legal, etc. $ 1.2M FF&E $ 2.0M Owner’s Contingency (5%) $ 0.7M Project Costs Subtotal* $ 3.9M Project Total (Phase 3)* $ 20.1M Project Total (Phases 1 & 2)* $ 6.5M Project Total* $ 26.6M

Addition / Remodel - ALTERNATE PHASING (Phase 3)

* Costs in 2019 dollars; financing costs are NOT included Totals subject to rounding errors; Phase 3 costs do NOT include additional Inflation or mobilization costs

Nemaha Valley Community Hospital

15 July 2019